RESEARCH THE SURGICAL MANAGEMENT AND SPEECH AND SWALLOWING REHABILITATION

14 HEALTH SA GESONDHEID Vol.11 No.3 - 2006
RESEARCH
THE SURGICAL MANAGEMENT AND SPEECH AND SWALLOWING REHABILITATION
OF PATIENTS WITH ADVANCED TONGUE CANCER IN SOUTH AFRICA
Leanie Engelbrecht
M Communication Pathology
Masters student, Department of Communication Pathology, University of Pretoria
Anita Van der Merwe
D Phil (Speech Pathology)
Professor, Department of Communication Pathology, University of Pretoria
Corresponding author: [email protected]
Jan P Pretorius
M Med (Surgery)
Professor, Department of Surgery, Faculty of Health Sciences, University of Pretoria
Keywords: surgical management; speech and swallowing rehabilitation; advanced tongue cancer
ABSTRACT
Advanced tongue cancer may have a devastating effect on a person’s ability to speak and to swallow. Very little is
known about the surgical management and speech and swallowing rehabilitation of persons with advanced tongue
cancer in South Africa. The aim of this study was to obtain information regarding clinical practices in treatment and
rehabilitation. Questionnaires were distributed to 450 surgeons and 150 speech-language pathologists in South
Africa. The response rate was 16% for the surgeons and 33% for the speech-language pathologists. Results
showed that only a small number of surgeons and speech-language pathologists in South Africa are involved in the
treatment of persons with advanced tongue cancer. Surgeons prefer combined modality treatment (surgery and
post-operative radiotherapy) in the primary treatment of patients with advanced tongue cancer, but the use of radio-
chemotherapy is growing. Total glossectomy is a very radical procedure, but it is sometimes used by surgeons to
treat patients with advanced disease. Total glossectomy with laryngeal preservation is preferred to total glosso-
laryngectomy by surgeons, in order to preserve laryngeal voice. Patients with total glossectomy form only a small
part of the caseload of speech-language pathologists. Swallowing rehabilitation includes aspects such as dietary
changes, compensatory swallowing techniques and airway protection mechanisms. Speech intelligibility is targeted
in speech rehabilitation, but alternative communication is sometimes recommended for patients who have under-
gone total glosso-laryngectomy.
OPSOMMING
Gevorderde tongkanker het ‘n geweldige impak op ‘n persoon se vermoë om te praat en te sluk. Baie min inligting
is bekend oor die chirurgiese behandeling en spraak- en slukrehabilitasie van persone met gevorderde tongkanker
in Suid-Afrika. Die doel van hierdie studie was om inligting te verkry aangaande die kliniese praktyk in behandeling
en rehabilitasie. Vraelyste is aan 450 chirurge en 150 spraak-taalterapeute in Suid-Afrika gestuur. Die responssyfer
was 16% vir die chirurge en 33% vir die spraak-taalterapeute. Resultate toon dat slegs ‘n klein aantal chirurge en
spraak-taalterapeute in Suid-Afrika betrokke is by die behandeling van pasiënte met gevorderde tongkanker.
Chirurge verkies kombinasie behandeling (chirurgie met post-operatiewe radioterapie) in die primêre behandeling
van pasiënte met gevorderde tongkanker, maar die gebruik van chemo-radioterapie is besig om toe te neem. Totale
glossektomie is ‘n radikale prosedure, maar word soms deur chirurge uitgevoer om pasiënte met gevorderde siekte
te behandel. Totale glossektomie word verkies bo totale glosso-laringektomie deur chirurge ten einde laringeale
stem te behou. Totale glossektomie-pasiënte vorm ‘n klein gedeelte van spraak-taalterapeute se gevalslading.

15
HEALTH SA GESONDHEID Vol.11 No.3 - 2006
Slukrehabilitasie sluit aspekte soos dieetaanpassing, kompensatoriese sluktegnieke en lugwegbeskermingstegnieke
in. Spraakverstaanbaarheid word geteiken in spraakrehabilitasie, maar alternatiewe kommunikasie word soms
aanbeveel vir pasiënte wat totale glosso-laringektomie ondergaan het.
INTRODUCTION AND BACKGROUND
The rehabilitation of patients with head and neck cancer
has evolved into “a very complex speciality, demanding
expertise in various disciplines” (Shah, 1996:iv). In South
Africa many patients present with advanced head and
neck cancer as a result of the large number of patients
coming from rural areas. A great number of these
patients need radical treatment because of the advanced
stage of the cancer at the time of presentation. Very
little is known about the surgical procedures and
practices of South African head and neck surgeons
regarding the treatment of advanced tongue cancer
patients. Surgeons may choose from a variety of
treatment options, or refer the patient for radiotherapy
and/or chemotherapy. The nature of the medical
treatment (for example surgery, radiotherapy or
chemotherapy) will impact on the rehabilitation needs
of the patient, including speech and swallowing
rehabilitation. Little is known about speech-language
pathologists’ experience of treating patients with
advanced tongue cancer and their knowledge of the
effects of surgical treatment on communication and
swallowing. Currently, there is no standard approach
followed in medical institutions in South Africa regarding
the surgical management and rehabilitation of patients
with advanced tongue cancer. It is therefore essential
to establish a database of information regarding the
surgical management and speech and swallowing
rehabilitation of patients with advanced tongue cancer
in South Africa. For the speech-language pathologist
to effectively treat speech and swallowing problems of
patients with advanced tongue cancer, it is important
to be acquainted with the current practices regarding
the surgical management of these patients. However,
patients who undergo treatment for tongue cancer have
many diverse needs and a multidisciplinary team
consisting of a professional nurse, physiotherapist,
psychologist, social worker, surgeon, radiotherapist and
oncologist thus has a crucial role to play in the
management of patients with head and neck cancer.
Oncological and surgical management of
advanced tongue cancer
The treatment of advanced tongue cancer is a con-
troversial issue in head and neck oncology with
important implications for the patient in terms of post-
treatment functioning and quality of life (Mendenhall,
Stringer, Amdur, Hinerman, Moore-Higgs & Cassisi,
2000:35; Harrison, Ferlito, Shaka, Bradley, Genden &
Rinaldo, 2003:101). Several treatment options are
available, including surgery, radiotherapy and chemo-
therapy, or a combination of these procedures.
Combined modality treatment (for example, surgery and
post-operative radiotherapy or chemo-radiation) is
required for patients with advanced disease. Surgical
resection, followed by immediate reconstruction, neck
dissection (unilateral/bilateral) and post-operative
radiation therapy is considered the favoured combination
of treatment modalities for patients with advanced
tongue disease (Salibian, Allison, Rappaport, Krugman,
McMicken & Etchepare, 1989:513; Sultan & Coleman,
1989:298; Shah, 1996:175; Mactay, Perch, Markiewicz,
Thaler, Challian, Goldberg, Kligerman & Weinstein,
1997:495; Ruhl, Gleich & Gluckman, 1997:1316;
Robertson, Gleich, Barrett & Gluckman, 2001:1364).
However, the role of combined chemo-radiotherapy in
the treatment of advanced tongue cancer is growing
(Harrison et al. 2003:101).
When surgery is performed, total glossectomy is often
required in cases of advanced tumours (referred to as
T3 or T4 depending on the size of the tumour) that affect
the whole tongue or the base of the tongue (Shah,
1996:179; Götert & Aras, 1999:75). The efficacy of total
glossectomy for advanced carcinoma of the tongue
remains controversial (Sultan & Coleman, 1989:297).
This procedure necessarily impacts permanently upon
both speech and swallowing (Davidson, Brown &
Gullane, 1993:163). When the tumour involves the
valleculae or pre-epiglottic space, total laryngectomy
also needs to be performed to obtain clear surgical
margins. This operation is known as a total glosso-
laryngectomy. An important reason for performing total
glosso-laryngectomy is to prevent the aspiration of food
that may follow after total glossectomy. The main
implication of total glosso-laryngectomy is that laryngeal
voice is lost. However, the advantage is that aspiration

16 HEALTH SA GESONDHEID Vol.11 No.3 - 2006
is eliminated. Total glosso-laryngectomy is extremely
radical surgery. Harrison states that total glosso-
laryngectomy should be “viewed as a last resort, as
the functional and psychological consequences are
profound” (Harrison et al. 2003:102).
Communication and swallowing prob-
lems following total glossectomy and total
glosso-laryngectomy
The general perception is that intelligible speech without
a tongue is not possible. To the contrary, numerous
studies indicate that fairly intelligible speech is possible
after total glossectomy (Morrish, 1984:125; Morrish,
1988:13; Davidson et al. 1993:160; Knuuttila, Pukander,
Määttä, Pakarinen & Vilkman, 1999:621; Fox & Rau,
2001:161; Furia, Kowalski, Latorre, Angelis, Martins,
Barros & Ribeiro, 2001:378). According to Knuuttila et
al. (1999:622) speech can be astonishingly intelligible
after a total glossectomy, even though the tongue is of
central importance for the production of consonants and
vowels. Speech intelligibility can be enhanced by
teaching the patient compensatory speech techniques,
such as overemphasis of suprasegmental aspects of
speech (reduced speech rate, stress and intonation).
Speech intelligibility is also enhanced by the fact that
listeners “fill in” information not clearly articulated by
the speaker. Perception of speech is thus facilitated
by the large amount of redundancy in normal speech
(Morrish, 1988:13).
Preservation of the larynx is obviously of great help in
developing good post-glossectomy speech (Harrison,
1983:633). If a total glosso-laryngectomy is performed,
laryngeal voice is lost. All authors agree that when the
larynx is sacrificed, so is the potential for acceptable
speech rehabilitation. Weber, Ohlms, Bowman, Jacob
and Goepfert (1991:513) and Davidson et al. (1993:162)
state that when the larynx is sacrificed, acceptable
speech rehabilitation is not possible. Total glosso-
laryngectomy causes sudden and complete loss of
speech (Fox & Rau, 2001:161). Tracheo-oesophageal
speech offers a possible solution to these patients and
alternative communication aids can also be
implemented. However, if the patient is illiterate,
alternative communication may not be an option or may
be restricted to picture-based communication.
Total glossectomy will not only compromise speech,
but also the patient’s ability to chew and swallow food.
Swallowing problems, also referred to as dysphagia,
may occur. The major cause of dysphagia after total
glossectomy is a lack of force to transport the bolus
from the oral cavity to the pharynx, and from the phar-
ynx to the oesophagus (Furia, Carrara de-Angelis,
Martins, Barros, Carneiro & Kowalski, 2000:382). Pa-
tients who have undergone total glossectomy are usu-
ally dependent on a liquid or puree diet because of the
lack of oral propulsive force. Procedures such as laryn-
geal suspension and cricopharyngeal myotomy that
facilitate bolus transportation from the oral cavity to the
oesophagus, may be useful in improving swallowing
after total glossectomy (Hirano, Kuroiwa, Tanaka,
Matsuoka, Sato & Yoshida, 1992:140).
General swallowing characteristics noted on
videofluoroscopy after total glossectomy with preser-
vation of the larynx are an increase in oral transit time
and stasis of food in the oral cavity, pharynx and above
the superior oesophageal sphincter (Ruhl, Gleich &
Gluckman, 1997:1317; Furia et al. 2000:379). Patients
who have undergone total glossectomy use compen-
satory swallowing techniques and swallowing
manoeuvres to improve swallowing. Compensatory tech-
niques include head tilting to direct food posteriorly,
increased buccal, mandibular, pharyngeal and laryn-
geal activity and voluntary protection of the larynx dur-
ing swallowing. Movements comprising lip protrusion,
suction, and intra-oral space reduction through man-
dible movements also facilitate swallowing.
The need for a survey of the surgical man-
agement and speech and swallowing re-
habilitation of patients with advanced
tongue cancer in South Africa
South Africa poses novel challenges to medical practi-
tioners and rehabilitation team members. Patients com-
ing from both first and second world settings have to be
managed according to their needs. The treatment of
advanced tongue cancer is in most instances radical
and will have profound implications for the life-style of
patients. Professionals have to be trained to serve this
diverse population with their specific needs. At present
very limited data on the surgical management and
speech and swallowing rehabilitation practices are avail-
able. The present study is a preliminary attempt to
determine the nature of current practices in South Af-

17
HEALTH SA GESONDHEID Vol.11 No.3 - 2006
rica regarding surgical procedures and speech and
swallowing rehabilitation, and also to determine how
many surgeons and speech-language pathologists are
involved in the treatment of advanced tongue cancer.
RESEARCH
Aim of the study
The aim of this study was to determine current prac-
tices in South Africa regarding the surgical manage-
ment, and speech and swallowing rehabilitation of pa-
tients with advanced tongue cancer.
Research design
An explorative survey design was followed (Neuman,
1997:20). The data collection tool was a mailed and
self-administered questionnaire. Questionnaires were
distributed to surgeons and speech-language
pathologists in South Africa.
Participants
Participants comprised two subgroups, namely sur-
geons (including general surgeons, ear, nose and throat
surgeons, and maxillo-facial and reconstructive sur-
geons) and speech-language pathologists. Question-
naires were sent to each of the 220 practising ear, nose
and throat specialists and each of the 90 practising
maxillo-facial surgeons in South Africa. Questionnaires
were also sent to a total of 140 general surgeons and
plastic and reconstructive surgeons. Simple random
sampling was used to select these 140 surgeons.
Speech-language pathologists in private practice and
at academic hospitals were included in the study. A
total of 50 questionnaires were sent to speech-language
therapists working in academic hospitals. All the aca-
demic hospitals in South Africa were included. Ques-
tionnaires were sent to 100 therapists in private prac-
tice. Simple random sampling was used to select the
speech-language pathologists in private practice.
Questionnaires were thus distributed to a total of 450
surgeons and 150 speech-language pathologists.
Seventy-three surgeons (16%) and 55 speech-language
pathologists (33%) returned their questionnaires. Of the
73 surgeons, only sixteen were involved in the treatment
of patients with advanced tongue cancer. Of the 55
speech-language pathologists, 13 were involved in the
treatment of patients who have undergone total
glossectomy.
Material
Two questionnaires were compiled. The one question-
naire was developed to determine case load and current
practices in surgical management of advanced tongue
cancer by surgeons and the other questionnaire was
aimed at determining case load and current practices
in speech and swallowing rehabilitation by speech-
language pathologists.
The surgeons’ questionnaire contained questions
regarding caseload, modalities of treatment (surgery,
radiotherapy and chemotherapy), the utilisation of total
glossectomy versus total glosso-laryngectomy in the
primary treatment of patients with advanced tongue
cancer, referral practices and survival rates after total
glossectomy.
The speech-language pathologists’ questionnaire in-
cluded questions regarding caseload, speech and swal-
lowing rehabilitation of total glossectomy patients, re-
ferral practices and the need for more intensive under-
graduate training. Speech rehabilitation may entail com-
pensatory articulation training or the implementation of
augmentative and alternative communication methods.
Swallowing rehabilitation refers to the techniques intro-
duced by the speech language pathologist to aid the
patient in overcoming the difficulties in swallowing cre-
ated by total glossectomy. The range of methods aimed
at improving swallowing may consist of various com-
pensatory swallowing techniques, feeding aids and diet
modifications. Questions on all of these aspects of re-
habilitation were included in the questionnaire.
To enhance response rates, questionnaires were kept
relatively short. Questionnaires were accompanied by
information letters and a request for participation by
two widely known head and neck surgeons in South
Africa. Surgeons were reminded via electronic mail to
respond to the questionnaires. Speech-language
pathologists were phoned and reminded to respond to
the questionnaires.

Reliability and validity of the questionnaire
To ensure the reliability and validity (Neuman, 1997:140)
of the questionnaire, experts were consulted with re-
gard to content and formulation of questions and then
a pilot study was conducted. Two surgeons (one gen-
eral and one ear, nose and throat surgeon) and a
speech-language pathologist experienced in the field
of head and neck cancer were asked for input regard-
ing the questions in the questionnaire. The preliminary
questionnaire was then completed by two other sur-
geons and two other speech-language pathologists. The
four pilot subjects were interviewed to discuss the as-
pects of the questionnaire that needed refinement.
Changes were then made to the questionnaire.
Data analysis
Each participant received a number as the question-
naires were received. The data were processed there-
after by means of descriptive statistics. A frequency
table was compiled for each question. An absolute
frequency analysis was applied as the aim was to
determine the number of positive and negative responses
to each question or to determine the number of
individuals in different categories. The data were sum-
marised in tables and figures, according to the
categories of the questionnaire.
RESULTS
Current practices in surgical management
Surgeons were asked to indicate the number of pa-
tients with advanced tongue cancer treated annually
and the surgical procedures that they perform on pa-
tients with advanced (T3 & T4) cancer of the tongue-
base. They were asked to provide an estimated num-
ber and not an exact number, as it was foreseen that
this would foster a higher return rate from surgeons
who have been practising for a great number of years in
busy practices. As there are not that many patients
who undergo glossectomy, the estimated number should
be fairly accurate. The results are shown in Table 1.
The number of patients with T3 or T4 cancer of the
tongue or tongue-base treated by the 16 participants
ranged between one and fifty annually. Participants
treated an average of 10 patients with this type of can-
cer per year. The biggest annual caseload of patients
(50 patients by two participants respectively) with ad-
vanced tongue cancer were reported by surgeons work-
ing in both academic hospitals and in private practice,
as opposed to surgeons in private practice alone.
With regard to the utilisation of total glossectomy, six
of the 16 surgeons never perform total glossectomy or
any variation of it; four of the 16 surgeons only perform
total glossectomy with laryngeal preservation; one of
the 16 surgeons performs both total glossectomy with
laryngeal preservation or total glossectomy with partial
laryngectomy; two of the 16 surgeons only perform to-
tal glosso-laryngectomy (thus never preserving the lar-
ynx); and three of the 16 surgeons perform all the varia-
tions.
Five participants who perform total glosso-laryngectomy
indicated that this is done to prevent chronic aspira-
tion. Six participants who do not resect a healthy lar-
ynx justified this choice with the following reasons:
surgery is unnecessary if there is no cancer in the lar-
ynx (take an adequate margin but treat the larynx on
its merits); the loss of voice together with swallowing
problems is tragic in view of survival; the rehabilitation
of speech and swallowing after total glosso-laryngec-
tomy in South-African black patients with disadvantaged
backgrounds is very difficult; a laryngectomy can al-
ways be done at a later stage; it depends on the mobil-
ity of the epiglottis.
There are alternative modalities of treatment available
for the treatment of T3 and T4 cancer of the tongue,
apart from surgery. Surgeons were asked to indicate
the modalities or combination of modalities used in the
treatment with these two different stages of tongue
cancer. The results are summarised in Tables 2 and 3.
Surgical resection (as single modality treatment) is
utilised by 10 of the 16 participants (four always and
six sometimes), while two participants never make use
of surgical resection. Radiotherapy (as single modality
treatment) is used by 12 participants (six always and
six sometimes); one participant never makes use of
radiotherapy. The combination of surgical resection and
post-operative radiotherapy is used by 14 participants
(seven always and seven sometimes). Brachytherapy
(as single modality treatment) is used by six partici-
pants (one always and five sometimes), while four par-
18 HEALTH SA GESONDHEID Vol.11 No.3 - 2006